By Craig Parker

Healthcare experts highlight the need for an expanded support service solution for hospitals and provider groups that have increased capabilities to promptly and effectively resolve non-clinical factors -- which account for 80% of patient issues. The problem is that most “patient navigation” programs are failing to address these factors because they don’t achieve meaningful patient activation. While they may focus on engagement, they fall short in identifying the right patients or talking about the right things for the right amount of time.

Because they are so good at clinical care, hospitals and health systems are always tempted to try to build non-clinical patient interaction programs because of the close connection to clinical care. After all, the whole point is to try to get the patients to be more aware of what they need to be doing and to be more compliant.

However, having too great an emphasis on the clinical side of this kind of patient interaction can be counterproductive. Patients can be intimidated by clinical staff, and therefore reluctant to share issues centered in the social determinants of health. Having clinical staff work on social determinants and non-clinical issues is, by definition, below top of license.

This is precisely where an outsourced “care guidance” program and partner can be of such value. Using the right personnel, trained and supported by structured workflows can increase bilateral patient communication, better identify barriers, produce effective resolution and provide curated information to the clinical team when escalation is necessary.

A structured and scaled care guidance program that goes beyond mere patient navigation provides an effective support service that is moving the needle forward. By extending the services of existing clinical staff and strengthening patient management outside the walls of the hospital, healthcare organizations more effectively address the challenges during the continuation of care.

Addressing social determinants of health
Care guidance takes into account the role of social determinants of health (SDoH), with personalized services provided by skilled and trained care guides that recognize these non-clinical factors that influence an individual’s ability to access care and adhere to treatment. It’s this “human touch” that supports patients who are at-risk based upon SDoH characteristics and frequently require amplified levels of activation and monitoring that cannot be addressed within the typical hospital’s resource capacity and clinical scope limitations.

SDoH are categorized by socioeconomic, education, cultural and environmental domains. Sub-standard conditions among these domains are shown to perpetuate patient health disparities, contribute to their unmet resources, services and transportation needs and widen health inequities, especially affecting those with chronic health conditions. If SDoH issues are not addressed and promptly resolved, they can lead to health deteriorations, higher rates of clinical service utilization, extended hospitalizations or readmissions and a higher total cost of care.

A tech enabled, human-activated patient solution
Modern care guidance goes beyond a mere support role in terms of scope and function. It is a pro-active solution to resolve disparity-driven barriers to accessing and receiving care and to adhering to care plans. Innovative health systems are partnering with care guidance services to implement programs focused upon prevention and pre-emptive interaction with patients -- before non-clinical issues become problematic and costly.

Care guidance has evolved to include both non-clinical conversations as well as systemized assessments to support disease-specific clinical conditions with a tech-enabled, human-activated solution. Specially screened and trained care guides can skillfully perform non-clinical tasks such as scheduling follow-up appointments, helping patients understand and adhere to their treatment plans and ensuring their medication compliance.

Implementing a care guidance program provides patients with a higher level of personalized and preventive care. As a result, providers and clinicians are able to focus upon patient-centered care that generates optimal outcomes and enable patients to return to a normal degree of function and quality of life. Hospitals and their clinical staff receive the extended support they need to advance health equity and deliver care that increases patient experience and satisfaction.

How care guidance works
Care guidance programs rest largely on specially selected and tech-enabled “care guides” who work to establish a peer-to-patient connection with patients and their families. This human-led approach builds trust and enhances a patient’s ability to communicate.

The human touch in care guidance is indispensable, as automated technology alone cannot supplant the personal connection forged through patient interaction. This is especially true considering the limited abilities certain patients have in accessing digital health technologies, and potential use impairments among disabled, disadvantaged and senior populations.

If tech-only approaches could solve readmissions and decrease avoidable utilization, the U.S. health system would not have a problem with unnecessary acute utilization. But we do have that problem and it’s time to recognize that the digital-only solutions, while helpful, are not standalone solutions.

The right mix of human and tech elements, integrated together, support personalized and meaningful peer-to-patient relationships and personalized communication in providing patients and their families with the connected support they need to stay on track and engage in the management of their condition throughout their care continuum.

Optimally, care guides are equipped with scalable, technology platforms that provide structured workflows and use evidence-based disease and condition-specific protocols to proactively identify and resolve practical and non-clinical barriers experienced during their care. A patient activation platform that augments a hospital’s care management workflow and automates protocols helps uncover both non-clinical and clinical issues and barriers. With this technological support, care guides ensure that non-clinical issues get promptly resolved and clinical issues are immediately escalated to proper clinical care teams.

Extended support to alleviate critical nursing shortages
A key value proposition of care guidance is its impact upon the nursing shortage.

The American Organization for Nursing Leadership (AONL) recommends looking for opportunities to offload and alleviate time-consuming tasks. Nurses engaged in patient navigation and care coordination report that a significant amount of their workload is spent addressing non-clinical patient issues and practical tasks. Assigning nurses and clinical staff with burdensome responsibilities beyond their scope of practice can lead to dissatisfaction, burnout, turnover and shortages.

As healthcare organizations experience the profound financial impact of nurse shortages, care guidance is providing an innovative and efficient solution. The addition of a care guidance program, beyond mere navigation efforts, provides organizations with truly effective supplementary support services, functioning as a lower cost extension of clinical teams and freeing up labor, time and resources so that nurses can focus on high-value clinical tasks.

Data captures strategic insights
An effective care guidance platform also captures SDoH data and disparity-related barrier resolution, exceeding the capabilities of typical electronic health record (EHR) systems which are not specifically designed to facilitate the kind of resolution workflows that are needed to address health equity and SDoH issues. A specialized platform facilitates operational improvement by seamlessly exchanging relevant insights for each patient population.

Data analytics within the platform provide insight into non-clinical issues, identify probable SDoH risks and facilitate personalized communication. By gathering condition- and journey-specific data on thousands of patients, a care guidance platform can take advantage of machine learning to anticipate patient needs based upon condition-specific protocols that enable care guides to deliver an unprecedented level of vital, just-in-time communication.

This is different than AI, which is not likely to be successful in facilitating this kind of patient activation unless the AI tool can be trained using the thousands and thousands of journey-specific data points – which don’t actually exist in large EHR systems. Taking advantage of machine learning insights, care guides provide patients with the information they need to engage in the process of their care and empower each consumer to receive a better understanding of the treatment plan and options.

Achieving success in quality payment programs
A growing number of providers are electing to participate in value-based care arrangements that link payments to measured health equity improvements and overall quality performance indicators. A CMS initiative that is helping advance health equity is the introduction of the Quality Payment Program as a value component to the Accountable Care Organization model.

There are many options for providers to explore participation in CMS programs. Care guidance support to supplement clinical protocols with social determinants efforts pave the road to successful contracting. No matter which programs a provider is considering, the common element is the need to better identify, document and resolve barriers embedded in social determinants and drivers of disparities, initiatives that advance health equity for all patient populations.

The Bottom-line benefits of outsourced care guidance
The addition of a care guidance program beyond mere navigation efforts provides a unique solution-as-a-service. Collaboration between hospitals, providers and care guidance teams supports a triad of care coordination and management. Hospitals and their clinical staff receive the extended support they need from a dedicated care guidance service:

• Reaching and managing more patients, maintaining their continuity of care.
• Removing non-clinical tasks from the workloads of nurses and clinical staff.
• Performing follow-ups and monitoring, conducting follow-up tasks and ensuring that potential issues and barriers are proactively identified and resolved.
• Scheduling appointments, screenings, preventive care and annual wellness visits.
• Ensuring compliance, adherence and medication management.
• Reducing unnecessary service utilization and avoidable readmissions.

Care guidance is a rapidly emerging opportunity as all stakeholders need support to help navigate the complexities of the U.S. healthcare system. Getting the right care at the right time and the right place is an ongoing challenge. Even harder is making sure the provider team is talking to the right patients about the right things for the right amount of time.

The good news is that care guidance works to accomplish these objectives while concurrently supporting healthcare’s “triple aim” of improving the patient’s healthcare experience, improving quality of care and reducing total costs. Functioning as a lower cost extension of a hospital’s clinical team, specially trained care guides free up labor, time and resources so that providers can focus on providing high-value clinical tasks and patients/health plan participants are able to receive equitable and affordable health care.

About the Author: Craig Parker, JD, CPA, CEO, Guideway Care, has spent most of the last twenty-five years operationalizing solutions that leverage technology and people to improve patient care and outcomes.